護理師照護一位重大燒傷病人。在最初的 24 小時內，哪項評估最重要？
A nurse is caring for a client with a major burn injury. During the first 24 hours, which assessment is most important?
- AFluid volume and urine output✓ 正解體積量與尿量
- BNutritional intake and caloric count營養攝取與熱量計算
- CRange of motion in affected joints患部關節的活動範圍
- DWound infection status傷口感染狀況
重大燒傷病人在最初的24小時內，面臨著嚴重的生理適應挑戰。這個階段被稱為「休克期（resuscitation phase）」，其主要病理生理學特徵是毛細血管通透性（capillary permeability）急劇增加，導致大量的血漿和電解質從血管內空間滲漏到組織間隙，形成嚴重的組織水腫。這種大規模的體液外滲會導致有效循環血量（effective circulating volume）急劇下降，若不及時補充，將迅速發展為燒傷性休克（burn shock），進而導致器官灌流不足和多重器官衰竭。 因此，在最初的24小時內，護理師最關鍵的評估和干預目標是維持病人的體液平衡和器官灌流。尿量（urine output）是評估腎臟灌流和全身循環血量是否足夠的最直接、最可靠的臨床指標。適當的液體復甦應維持成人每小時0.5-1.0 mL/kg的尿量。監測體液輸入量和尿量，能讓護理師即時調整輸液速度，確保病人獲得足夠的液體，以預防或治療燒傷性休克，保障生命安全。這是應用「ABC（Airway, Breathing, Circulation）」原則中循環（Circulation）的優先考量。
During the first 24 hours after a major burn (resuscitation/emergent phase), capillary permeability increases dramatically and large volumes of plasma shift from intravascular to interstitial space, causing burn shock if not corrected. Adequate fluid resuscitation (e.g., Parkland formula) is the priority, and urine output (target 0.5-1.0 mL/kg/hr in adults) is the most reliable bedside indicator of organ perfusion and resuscitation adequacy. Wound infection becomes a concern after 48-72 hours; nutrition and ROM are priorities in later phases.